The Under-Representation of Osteopathic Physicians in Plastic Surgery

October 2024 | Vol. 68, No. 1
Written by Nura Gouda OMS-IV, Marshall Miles D.O., Michael Karon D. O. Institutions: Gouda- Philadelphia College of Osteopathic Medicine, Philadelphia, PA Dr. Miles – Lehigh Valley Health Network, Allentown PA Dr. Karon- Reading Hospital West Reading, PA

Plastic surgery residency is arguably one of the most competitive specialties in which to match. Many factors can increase one’s chances of matching, such as high board scores, strong letters of recommendation, multiple research publications, and outstanding performance on fourth year rotations. However, while reviewing match data from recent years published on the NRMP website (1), it was apparent that one specific factor had a grossly negative association with a successful match: attending an osteopathic medical school (DO) rather than an allopathic medical school (MD). The osteopathic philosophy of medical education was created in 1874 with the intent of approaching patient health and treatment holistically, viewing the patient as a culmination of their mind, body and spirit, and practicing on the assumption that these three aspects exist synergistically (2). Additionally, osteopathic manipulative treatment (OMT), which DO physicians are taught during their training, involves the use of one's hands to understand and identify somatic dysfunction based on an understanding of the musculoskeletal system. Besides this additional training, osteopathic and allopathic medical students receive the same medical education. Integration of OMT into treatment of patients is often physician and specialty specific.

To date, DO physicians are found practicing and training successfully in every medical and surgical specialty in throughout the nation. Though historically DO physicians were mainly found in primary care specialties, there has been increasing amounts of osteopathic physicians matching into non-primary care specialties each year. Despite this steady increase in representation, plastic surgery remains at a stark deficit of osteopathic to allopathic physicians. Our article discusses current data on DOs in plastic surgery training and practice, trends reflected in the American Society of Plastic Surgeons (ASPS), and predicates why this under-representation persists in the field of plastic surgery, despite increases in osteopathic physician representation among all other medical specialties.

After the formation of a single accreditation system on June 30th, 2020, which combined the AOA and AACOM programs with currently existing ACGME programs, DO graduates and MD graduates have been applying into a single match system (3). In years prior to this, DO applicants would choose to apply either to osteopathic (AOA/ AACOM) or allopathic (ACGME) residency training programs. The merging of residency programs was aimed to create more equal training opportunities and since its integration, the number of DO students in non-primary care specialties has been markedly increasing. Yet, within the specialty of plastic surgery, DO senior matches each year remain very low and in fact are often zero.

Match data found on the National Resident Match Program (NRMP) separates applicants by degree (DO/MD/IMG MD) and further distinguishes DO seniors and DO graduates who applied and matched into an integrated plastic surgery categorical position from the years 2019- 2023. DO graduates are defined as a DO student who either completed additional training or a research year prior to successfully matching, while DO seniors are defined as a 4^th year DO student. Despite a combined match, there have only been 3 DO senior applicants accepted into an integrated plastic surgery categorical position within the last 5 match cycles 2019-2023 (Table 1). With only one DO graduate per year, from the years 2019-2023, successfully matching. Of note, the number of DO senior applicants from years 2020-2023 has been steadily decreasing by half each year. From years 2021-2023, the number of DO applicants decreased respectively from 20 to 10 to 5 (1). This was particularly interesting as it was conversely found that the number of integrated programs and spots had increased from 2019-2023 (78-91 spots), likely due to the transitioning of independent plastic fellowships into integrated programs. With these increases, it was unexpected to see an opposite trend in the number of DO applicants and acceptances. However, data in Table 1 on MD senior applicants trended upwards with applicant numbers increasing steadily from 188 to 255 from 2019-2023, in addition to increases in match rates as well (75.8%, 77%, 68.7%, and 80.8% respectively). With the increase in integrated positions, data seemed to reflect preferential benefit to MD applicants only.

In 2021, osteopathic residents in plastic surgery training programs comprised only 2.3%, with only 28 out of 1,213 total residents/fellows being a DO (Table 2). That same year osteopathic resident representation was also low for radiation oncology (2.4%), neurosurgery (3.6%), thoracic surgery (4.0%), and ophthalmology (4.9%). Another notable finding was apparent when comparing DO representation between years 2015 and 2021, allowing us to evaluate change in representation before and after the 2020 merger. In the year 2015, osteopathic representation in plastic surgery, neurosurgery, otolaryngology, and orthopedic surgery were similarly all less than 1.0%, which categorized these specialties as ones with historically low DO representation (Table 3). Yet, when comparing change in representation among these identified specialties from 2015 to 2021, plastic surgery had the lowest increase with otolaryngology (ENT) having the highest. In 2015, representation was 0.3%, 0.8% and 0.8% with increases to 6.2%, 12.7% and 2.3% for ENT, orthopedic surgery, and plastic surgery respectively. Comparing the ratio of changes revealed a 21:1, 17:1 and 3:1 increase for these specialties respectively (ENT/Ortho/Plastics). While this general trend could be attributed to the effects of the 2020 merger, and in fact were similarly found among all specialties with low representation, plastic surgery seemed resistant to similar change.

While many reasons may explain this observation such as a lack of outreach or opportunities at the preclinical level, it is also worthwhile to consider DO students’ attitudes and desires towards pursuing a career in plastic surgery or lack thereof. It may be true that many osteopathic students feel as if there is a barrier, which may prevent a student from ever considering plastic surgery as a career. Other theories point to the lack of home training programs associated with osteopathic medical schools, limiting access to research and mentorship opportunities.

This under-representation was also found among plastic surgeons in practice as it was the specialty with the 2^nd lowest DO representation (1.7%) in 2021 (123 out of 7,228) (Table 4).

Radiation oncology had the lowest representation (1.6%) followed by neurosurgery (2.0%), thoracic surgery (2.3%) and urology (2.6%) (4). The last area we noticed this discrepancy, was among those with membership in the American Society of Plastic Surgeons (ASPS), which ended up being the most drastic. Information published on their website totaled over 5,000 members with only 19 being osteopathic surgeons, a staggering 0.37% (5). While rates of successful osteopathic matches, current residents, and current active physicians were persistently low, representation in the ASPS was by far the most shocking. Moreover, this under- representation in ASPS was doubly astonishing as the current president of ASPS at the time of writing this paper in 2023 was noted to be osteopathically trained (6).

It is important that this topic continues to receive attention and that efforts are made to increase inclusion of osteopathic physicians within the field of plastic surgery. It is our hope that through increased awareness changes can be made in medical education and medical student exposure, increasing accessibility and opportunity for students. In conclusion, it is crucial that we attempt to breakdown this tangible barrier felt by many osteopathic students and lead the way for those aspiring for a career in this field, a field with an abundance of potential for osteopathic influence and growth.

Tables:

Table 1. NRMP Data on DO seniors and Graduates in Plastic Surgery Integrated Residency,
https://www.nrmp.org/match-data-analytics/residency-data-reports/

Table 2. 2015-2021 DO Representation in Integrated and Independent Plastic Surgery Residency Programs, https://www.aamc.org/data-reports/workforce/data/active-physicians-do-degree-specialty-2021

Table 3. Ratio of Increase in Specialties with DO Representation Similar to Plastic Surgery, 2015-2021

Table 4. Active DO Physician Representation in Plastic Surgery and Other Specialties,
https://www.aamc.org/data-reports/workforce/data/active-physicians-do-degree-specialty-2021